At the present time, there are no drugs that have been proven to work in patients with papillary kidney cancer that has spread (metastasized) beyond the kidneys. Researchers are interested in determining whether the combination of the drugs bevacizumab and erlotinib can be used to treat metastatic papillary kidney cancer.

Hereditary Leiomyomatosis and Renal Cell Carcinoma (HLRCC) is an inherited type of papillary kidney cancer (it runs in families). Papillary kidney cancer can also occur sporadically, or without a family connection. More research is needed to determine whether treatments for papillary kidney cancer, such as bevacizumab and erlotinib, work in inherited or sporadic types of kidney cancer, and if so, whether there are any differences.

Objectives:

-To determine the effectiveness of the combination of bevacizumab and erlotinib as a treatment for patients with (1) metastatic HLRCC kidney cancer and (2) metastatic kidney cancer not associated with HLRCC (or sporadic papillary RCC).

Eligibility:

Individuals 18 years of age or older who have been diagnosed with papillary kidney cancer that has spread beyond the kidneys.

Participants may have either HLRCC or sporadic papillary kidney cancer.

Design:

Participants will be screened with a full medical history, physical examination, blood and urine tests, and CT and other scans to evaluate tumor size and treatment options.

Every cycle, participants will return for regular blood and urine tests. Every other cycle, participants will have imaging scans to assess tumor size and response to treatment. Female participants who have uterine fibroid tumors related to their kidney cancer may have additional scans to assess tumor size and response to treatment.

Participants will continue to receive treatment on the study until their tumors grow or spread to new areas (disease progression), intolerable side effects develop, a better treatment option becomes available, the study closes, it is unsafe to continue treatment, or the participant decides not to remain in the study.

Further Study Information

Background:

HLRCC is a familial cancer syndrome characterized by a propensity for developing renal cancer, uterine and cutaneous leiomyomas.The kidney cancer associated with HLRCC is associated with HLRCC is clinically aggressive and is characterized by unique histopathologic features that are sometimes described as type2 papillary RCC.

Germline mutations in fumarate hydratase (FH) are the genetic hallmark of HLRCC. Mutational inactivation of FH has been shown to result in VHL-independent upregulation of hypoxia inducible factor (HIF) and its downstream transcriptional targets.

The recognition that HIF upregulation may play an important role in the formation and propagation of renal cancer associated with HLRCC suggests that interventions directed against components of this pathway, such as VEGF and TGF-alpha/EGFR, may be of benefit in this patient population.

We propose to test the hypothesis that dual VEGF/EGFR blockade with bevacizumab/erlotinib is likely to be clinically active in patients with HLRCC associated RCC as well as those with sporadic papillary sporadic RCC.

To assess progression-free survival, duration of response, and overall survival

To investigate the effect of bevacizumab/erlotinib on circulating endothelial cells and endothelial progenitor cells and to explore the utility of these markers as surrogates of angiogenesis inhibition

To investigate the effect of bevacizumab/erlotinib on potential biomarkers of angiogenesis in plasma such as VEGF and soluble VEGFR2

To evaluate the prevalence of somatic FH mutations/inactivation in patients with sporadic papillary RCC

No history of major bleeding, recent or active myocardial ischemia, GI perforation, cerebrovascular accidents or other significant intercurrent illness

No coagulopathy or bleeding diathesis

No recent surgery (< 4 weeks or inadequately healed surgical scars)

Adequate organ function:

Adequate liver function (total bilirubin less than or equal to 1.5 mg/dL or < 3 times the upper limit of normal (ULN) in subjects with Gilbert s disease, and AST/ ALT less than or equal to 2.5 times the ULN)

Adequate renal function (creatinine less than or equal to 2.0 times the ULN or creatinine clearance > 30 mL/min)

Neutrophils > 1500/microL and platelets > 100,000

No brain metastases

No more than 2 prior regimens containing a VEGF-pathway inhibitor; no prior bevacizumab

Ability to understand and sign informed consent

Design:

Patients will receive a fixed dose of bevacizumab (10mg/kg IV every 2 weeks) and erlotinib (150mg/day po). Dose reductions and drug interruptions for unacceptable toxicity will be allowed.

Patients will be evaluated for response every 8 weeks using RECIST criteria

The study is based on an open label Simon two-stage minmax design stratified into two cohorts, 1) cohort 1- patients with HLRCC, and 2) cohort 2-patients with sporadic papillary RCC. In each cohort, 13 patients will be accrued in the first stage and will accrue a maximum of 20 patients. Accrual into and analysis of the two cohorts will be independent.

Measurable disease, defined as at least one lesion that can be accurately measured in at least one dimension (longest diameter to be recorded) as greater than or equal to 20 mm with conventional techniques or as greater than or equal to 10 mm with spiral CT scan.

No more than two prior regimens targeting the VEGF pathway; no prior bevacizumab therapy

Age greater than or equal to 18 years.

Performance status ECOG 0-2

Patients must have normal organ and marrow function as defined below: WBC count greater than or equal to 3,000/microL, absolute neutrophil count greater than or equal to 1,500/microL, platelet count greater than or equal to 100,000/microL, serum creatinine greater than or equal to 2 times the upper limit of reference range or creatinine clearance greater than or equal to 30 ml/min, AST and ALT less than 2.5 times the upper limit of reference range, total bilirubin less than 1.5 times the upper limit of reference range ( less than 3 x upper limit of reference range in patients with Gilbert s disease), alkaline phosphatase less than or equal to 2.5 times the upper limit of reference range (or less than than or equal to 5 times the upper limit of reference range if considered to be related to liver or bone metastases by the PI)

Recovery from acute toxicity of prior treatment for RCC (to less than or equal to grade 1 the active version of CTCAE or to a level permitted under other sections of Inclusion/ Exclusion criteria).

At least 4 weeks from completion of major surgery and a healed surgical incision

Negative pregnancy test (within 7 days of enrolment) in women of childbearing potential

Ability to understand and the willingness to sign a written informed consent document.

EXCLUSION CRITERIA:

Prior invasive malignancy of other histology, with the exception of adequately treated basal or squamous cell carcinoma of the skin, or any other malignancy for which the patient has not required treatment for three years.

Patients with known brain metastases unless treated with an appropriate modality with no evidence of progression/recurrence for greater than 3 months

Hypertension not controlled by medical therapy (resting systolic blood pressure greater than 140 mmHg or diastolic blood pressure greater than 90 mmHg on at least two occasions over a 24 hour period despite optimal medical management).

Pregnant women are excluded from this study because bevacizumab and erlotinib are anti-cancer agents with the potential for teratogenic or abortifacient effects. Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with these agents, breastfeeding should be discontinued if the mother is treated on this study

All men and women of childbearing potential must be willing to use effective contraception as determined by the principal investigator (including but not limited to abstinence, hormonal contraceptives (birth control pills, injections, or implants), intrauterine device (IUD), tubal ligation, vasectomy) from the time of enrolment to at least six months following the last dose of drug

Any known hypersensitivity to bevacizumab, erlotinib or other excipients of these drugs

Documented baseline proteinuria greater than 1000mg/day on 24 hour urine collection. Only patients with 1+ or greater proteinuria on UA and a spot urine protein:creatinine ratio of greater than 0.5 will undergo a 24 hour urine collection for quantitation of proteinuria.

Left ventricular ejection fraction less than 40% as measured on transthoracic echocardiogram.

Note: Information about this trial is from the ClinicalTrials.gov database. The versions designated for health professionals and patients contain
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